[roll call]. >> do we have a motion to approve? >> second. >> all in favor? >> aye. >> there is no public comment for that item. item three is the director to

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report. >> good afternoon, commissioners and the deputy director of ho -- of health. i will give the director's reports. i wanted to highlight that last week the director, as well as multiple staff members, including kelly from transitions and jeff who will be giving an update, as well as dr. lisa pratt from jail health went want to provide testimony on two key bills that the department has been heavily involved in. one is s.b. 40 which is sponsored by senator weiner on conservatorship. this is a cleanup bill from s.b. 1045, and then ab 1557, which is assembly member to that is sponsoring, it is specific treatment in the jails and getting reimbursement. both of those were highly successful, both of those bills made it out of committee and are

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progressing but the legislature. the second thing i wanted to talk about is there are several population health issues that are currently happening. one is, as you have seen in the news, increased measles that are happening throughout the country there's been a lot of focus on new york, but the bay area has also had several measles exposures, especially in santa clara county, but last week as well, a couple weeks ago, d.b.h. put out a health advisory around an exposure and exposure that occurred within san francisco's jurisdiction. if dr. on what's to come up and speak briefly on multiple issues, the only other thing was he will talk about a syphilis update, which ties into the awareness campaign that we will be doing, as well as for 20 preparations for this saturday in golden gate park. >> good afternoon.

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yes, as the dr. mentioned about the measles case that happened, it was an adult who had travelled into san francisco, had been on b.r.t., in a restaurant, caltrain, and sometimes we always debate whether we should do a public notification. in this case, we decided to do a public notification because we couldn't identify all the people who may have been exposed. we think the risk is very low, but it was an opportunity to get the word out there. if someone hadn't been vaccinated and they had been at this designated sights at the time, they should watch out for if they develop a rash. the other reason we thought we would get the word out is because there's been other cases in other counties as well. this is an opportunity to remind everybody to get vaccinated, and if you are following the news of what is happening in new york city, and across the country, i think we have hope had over 500 cases we may surpass a number of

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cases in the u.s. compared to the most recent rise. it is an ongoing and important issue. the other thing i want to bring up is that on for 20 -- 420 knows what for 20 means, but on april 20th, and in hippie hill or robin williams meadows there's going to be a gathering where people come together and consume cannabis, mostly smoking , cannabis currently -- public consumption of cannabis is currently not legal, but what we have done in the past, although purchasing cannabis is legal, you are not the -- you are not supposed to consume it in public. in the past we would have worked with city agencies in the communities in the board of supervisors to make sure that the event goes off as safely as possible. last year there were several overdoses from opioids, it was not related to the cannabis, there was an e.m.s. response. we want to make sure that people

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are aware. the key messages we are getting out there is if you choose to use cannabis, make sure you buy it from a regulated and permitted retail vendor, not to take any drugs off the street. last year there was an outbreak of synthetic cannabis that was contaminated with blood thinner and people back east had been dying from this and had been bleeding and died. they were over 100 cases of this contaminated synthetic cannabis. and the third area is to make sure that to keep an eye out for folks that if anybody is consuming and opioids, that they should carry naloxone and they should really take care of each other. we have very specific messages that went out with that. we will be activated on saturday and we are monitoring the hospitals, the e.m.s. system, and to make sure everything goes okay. the last thing i want to mention -- actually i want to mention one little thing about the

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cannabis. so the board of supervisors really past -- recently passed an ordinance that's going to be a pilot project to allow permitting for cannabis smoking at outdoor events. so this is new. you will be hearing more about that recently because it will present real challenges to us to allow people -- what we would do is we would waive our tobacco smoke law to allow people to smoke. that will -- there are concerns that this may turn back the? in terms of allowing people to smoke in general. so you will be hearing more about them. the last thing i want to mention is if you have been following some of the news around congenital syphilis and syphilis in general, but since 2013, there has been 750% increase in the number of congenital syphilis cases in the state of california. congenital syphilis has gone up

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in california. san francisco fortunately has not seen an increase in congenital syphilis, however, we are beginning to see an increase in syphilis in women. so from 2017 until 2018, 100 44% increase in syphilis cases, going up to 71 cases. twenty-five% of those women are homeless, and 35% reported using methamphetamine. we are going to be doing a communicable disease activation and mono -- mobilizing the communicable -- the community and network committee to focus on syphilis in women. we do not want to see any congenital syphilis take hold in san francisco. you will be hearing more about that as we move forward. >> and just a note, that the cannabis presentation around using and special events will actually come to committee. >> you will get all the details there, and that is all.

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>> any questions? >> so i think this is the first time that for 20 is on a weekend in a while, at weekday. so i was wondering whether you are anticipating a bigger crowd from farther away, and what the preparations are, how are you possibly estimating the volume of individuals. >> so last year they estimated, they think there was about 17,000, and we are making the assumption that it maybe up to 25,000, and so m.t.a., police, fire, e.m.s., everybody is anticipating bigger crowds. there will be free public transportation down to bart, they were closed off more streets, and they will have a lane to make sure emergency vehicles can get in. the other thing we did is the community health equity promotion branch organized with behavioural health services pharmacy, and we trained over 35 city staff to carry naloxone.

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staff will be out there for other purposes and they will carry naloxone. not only will we have a bigger e.m.s. presence, we will have park rangers and other staff carry naloxone. -- carrying naloxone. >> any questions from commissioners? okay, we will move on to general public comment. >> item four is general public comment. >> we have a two offers a public comment. i will call your name. the first is chelsea stewart and the second is ashley jackson. >> folks making public comment, i have a timer. when the timer no soft, finish your sentence and move on. >> good evening, health commission. my name is chelsea stewart, i'm a medical school candidates. i want to preview with my policy

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brief on adverse childhood experiences entitled "fighting resilience, adverse childhoods experience screening schools. i want to start off with a quote that reads, aces are the new cholesterol. if you don't screen for it and you don't look for it, you will never find it, but has more health impacts then than you can imagine, and that is by a doctor in hayward his. adverse childhood experiences are traumatic events experienced during childhood that have severe negative health implications on health in adulthood. it contributes to toxic stress by increasing stress hormones in the body and damaging the development of vital organs such as the brain. they are classified as emotional , physical, and sexual abuse, neglect, and household instability. having an incarcerated parent or a parent addicted to alcohol or other drugs all contribute to the manifestation of toxic stress. sixty-one-point 7% of adults in

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california have experienced at least one, and 16-point 7% have experience four or more. a person with four or more as to point to times as likely to have heart disease. almost 2.5 times as likely to have a stroke, and almost by because -- twice as likely to develop cancer. must be screened for to support children with increased risk for chronic illness and wellness bases. it must be available in schools to increase resilience. the problem here is that they're not being screened for, and this leads to misdiagnosed misdiagnosed adhd, untucked -- untreated toxic stress, and increased risk for poor health outcomes. my first recommendation is to involve this screening at all clinics in san francisco. my second recommendation is to supply wellness rooms at every elementary school with materials to give students emotional and behavioural outlets to relieve stress. this concludes my presentation and i thank you for your time.

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>> thank you. speak to you today as of now there is a 223 million-dollar annual fee that goes towards rape victims and that supersedes assault, murder, child abuse, drunk driving, robbery and arson , so as you can see, it is

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a very important topic that needs to be addressed, especially on college campuses. i believe that is a forum where people are most educated and they're open to education and corrections. so i would like to point out that so far, parts of the project that i have been doing with the san francisco school of medicine leader program is where supposed to go out into the community and create projects that influence those around us, and i have chosen this topic to go to my school, and we have put on an event this past march, 27 th, and it was very successful, and we provided self-defence courses, we passed out date rape drug detection test kits, we also provided them

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with a workshop entitled demystifying social media and sexual harassment, which covered a various range of topics. that brings me to today. how can you help? we would love for you to provide our schools all across california, and in here in san francisco, founding that would allow schools to enhance and upgrade their programs on this topic, as well as funds new opportunities that allow health professionals and advocates to take part in educational discussions with students, as well as required by law that all middle schools, high schools, community colleges and universities provide mandatory semester long courses surrounding consent and sexual assault topics that must be completed in order to graduate. educational supplements for the

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courses should accommodate the grade level of the students that are taking them, as well as be reviewed by licensed and medical professionals that are specialized in treating sexual assault survivors, and we would also like to have professionals specialize in anger management to also look over those courses. thank you for your time. >> thank you. >> thank you very much. seeing no more public comment, we will move on to the community and public health community update. we met before this meeting. we received presentations from dr. sung regarding how people who are experiencing homelessness engage with our city charge of behavioural health services, we received a very useful presentation about how a number of different programs, including street medicine and others engage with people who are experiencing homelessness and a number of other issues. we also got an update on progress in helping to develop a

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more medically sensitive prioritize asian tool used by the department of homelessness and supportive housing in order to ensure that medical issues are incorporated into that process. in addition, we received a presentation from the std prevention and strategic plan. we mentioned some of the statistics that we had heard about. dr. stephanie cohan gave a presentation along with a representative who has been engaged to support the department in the strategic planning process. dr. chow and i also participated in survey tools that they will be using for focus groups and other things as they move forward towards putting together a strategic plan. the process should be wrapping up by june. do you have anything to add?

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>> no, thank you. a very good summary. >> thank you. >> thank you. we will move on to assisted outpatient treatment update. >> good afternoon, commissioners it is always a pleasure to come and give an update on assisted outpatient treatments. as i was reflecting on this prior to the presentation today, i was speaking to my coworker and saying last time i gave this presentation i was about to give birth, and this year i'm just excited that my shoes match in the morning. >> can you introduce yourself, please. >> i am the director of forensic

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injustice involved behavioural health services. for the record, my shoes to match today. [laughter]. >> so this is an update on our first three years of implementation of assisted outpatient treatment, which covers the period of november of 2015 through december of 2018, and just to orient us back to the conversation of assisted outpatient treatment, 45 states have assisted outpatient treatment laws, although they do vary from state to state. california's outlaws are focused on prevention rather then response to a crisis. it was passed in california at -- as assembly bill 1421 in 2002 and subsequently adopted by our board of supervisors in july of 2014, and implemented in november of 2015. it was also named an evidence-based practice by the substance abuse and mental health services administration. in san francisco, and in california, it is referred to as laurette's law and is designed

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to work with individuals who have serious mental illness who were not engaged in care and are on a downward spiral, and there is strict legal eligibility to qualify for the program and there is nine different levels of eligibility, ultimately, what it allows us to do, and in certain circumstances, it is to pursue a civil court order which allows us to leverage the symbolic wait of the court and support an individual in accessing services. and ultimately, the goal of the program is to reduce negative incomes -- outcomes including hospitalization, incarceration, and victimization. in san francisco, we verdict -- we work very much to employ principles that are employed by all of our behavioural health services, including recovery and wellness and trauma informed care. part of the goal behind that was we really wanted a core petition to be the last resort. our primary goal was to do whatever we can and meeting people and this idea of whatever it takes and wherever it takes

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to engage individuals and voluntary services. part of our team for assisted outpatient treatment as we have a d.b.h. team, which works to receive referrals, to coordination of the court, and do the initial engagement and outreach for individuals. we also contract with ucsf citywide, which houses and assisted outpatient treatment team to support individuals who primarily have been court ordered into treatment, but also to provide linkage and support for individuals who have voluntarily agreed to participate in services and need bridging into long-term care. this gives you an overview of the calls that we have received for assisted outpatient treatment for the three years of implementation. in total, we have received 321 information only calls, where individuals wanted to know more about the program or consult on a case, and a total of 295 referrals. the number of referrals has been consistent to relatively across

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the year-to-year, although once slightly higher in 2018 with a total of 90 referrals, which accounts for 7.5 referrals per month on average. as you can imagine, this is a population who have very significant needs, and some of what we will talk about today is the length of time we work with individuals to stabilize them in the community, but also how intense intensive the work is to do that. in regards to referrals, the law is very specific about who is eligible to make a referral, and they are considered qualified referral parties. this includes immediate family members which the law defines as a parent, sibling, spouse, or adult child, and existing mental health treatment provider, so this maybe a hospital where someone is hospitalized, or a circumstance or somebody is not engaged in outpatient services but has an existing provider, and the provider is at a point where they may need to close a case because the individuals

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continuing to refuse services, but the provider leaves they meet the criteria and is concerned about their well-being it also includes a parole of probation -- or probation officer who is assigned to supervise the individual. it does not include general law enforcement. the police department aren't able to make referrals, however, we work closely with the police department so they have collateral information about cases that they may think will come our way they suspect maybe engaged with this. they provide that information to us. finally, an adult who is living with the individual. because family members are able to make referrals to the program , and it is unique in that way, it is not surprising that we have many referrals to come from family members. and total, most of our referrals come from family members and treatment providers, accounting for 90 2% of the referrals we receive. in regards to the location of where referrals come from.

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most of our referrals have originated from san francisco, which is consistent across the years. one of the things we found early on in the program, and what was surprising to us, and we did not anticipate, as we have a number of referrals to come from family members who are out-of-state, or their loved ones travelled to san francisco. that accounts for 80% of our referrals. in terms of demographics, this information is specifically for cases where we outreach and have contact with the individual, which is 129 individuals over the course of the program. most of the individuals that we have had contact with have been male, white, and between the ages of 26 and 45, and this is generally consistent with what we see in our larger system of care, however, it is slightly higher for african-american individuals and slightly lower for individuals who identify as latino. what i will note in terms of the individuals that we have had contact with, this is higher than what we anticipated when we

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were looking towards in plummeting the program. it was anticipated that roughly 30 individuals a year, we would have contact with, so again, this is higher, although it is very important work, and i think as you will see, it has been very beneficial for the individuals we have out reached. in terms of risk factors, this is looking at the 36 months leading up to referrals to assisted outpatient treatment, individuals have multiple risk factors, including homelessness, incarceration, psychiatric hospitalization, and a psychiatric emergency services. and many individuals we work with have histories of homelessness, experiencing homelessness is not one of the legal criteria to qualify for the program. this is where we get to the exciting part, in looking at the initial outcomes that we have. what's been very exciting about being at three years is that we now have been able to look at the overall impact of the program over a period of time.

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and what we see here is that there is a statistically significant reduction in mostly average contacts of psychiatric emergency services. as you can see, 80 1% of individuals had contact prior to working with a.o.t. and that is reduced to 47%, and then below we have the average monthly context before working with a.o.t. during our work with an individual and then after our work within individual. we have similarly have statistically significant reductions in the amount of time and individual stays on a psychiatric inpatient units. what you will see here is that amount of time goes up while we are working within individual, although we do not see this to be a negative outcome. what we attribute this to is that we are working very closely to monitor individuals for 5150 criteria so that when they meet the criteria, we are working to immediately move them into the appropriate clinical setting. we also work very closely with

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the hospital and the courts to advocate for individuals who remain at that clinic setting as indicated, and we have an opportunity to hold an individual's narrative, and gather history prior to our work with an individual so we can share that information with the hospital and work with them to make sure there is an appropriate discharge plan before somebody is released. what you do see as after work within individual, there is a sharp reduction in the amount of time that somebody stays on an inpatient unit, which suggest this is a long-term impact of the program. moving on to incarceration, again, we have another statistically significant reduction in time spent in jail, and this is our largest impact that we see for the program, which is very exciting. as individuals who have serious metal illness, we know, you do not need to receive services and we really want to move the

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services to outside of custody and that we have been really successful in accomplishing that so looking at individuals who have been court ordered to participate in treatment, this is, this covers a total of 31 petitions that we have filed with the courts, for 20 individuals. eleven petitions have been to renew existing petitions with the court, which can be done one time, an individual can be court ordered to participate in outpatient treatment for up to one year. again, we really look at court ordered treatment as a last resort for individuals, and under the health code, we have to engage individuals for a minimum of 30 days before we consider filing a petition with the court. of those 20 individuals, 17 cases move forward with a court process. of the 11 cases where we filed renewals, nine of those individuals agreed to continue with the court process and

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continue to work with assisted outpatient treatment, which i really think speaks to the work that we are doing. the other thing i would like to note to regarding our penetration rate, regarding cord petitions is treatment advocacy centre recently put forward a report regarding counties that have implemented a.o.t. in california thus far. our penetration rate for court orders is 3.1, which is higher than 60% of other counties. in total, in terms of demographics for these individuals, most individuals have been male, caucasian, in between the ages of 36 and 45, which is slightly older than what we see for the general population that we are working with throughout assisted outpatient treatment. they have very similar risk factors regarding crisis context and incarceration that we see in the general population for a.o.t. in terms of outcomes, this is too small of a population to do

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any statistical analyses, but we see similar reductions in crisis context and psychiatric emergency services, inpatient hospitalization and incarcerations, again with incarcerations being the most drastic drop. so in total, 13% of cases go to court, but we are able to successfully engage 60 9% of individuals in voluntary services. i apologize for the percentage not being in your presentation here, but i'm happy to report that 96% of individuals that we have connected to services, at the time of data collection, had remained engaged in services, and as a reminder, given the individuals are not engaged in services in order to qualify for a.o.t., this is a huge success that we have. we also find that working with individuals that sometimes assisted outpatient treatment is not enough to work with them,

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but they really do need a higher level of care. in those cases, we have been able to consult with and work very closely with the opposite -- office of conservatorship services to consider this. in total, 16 cases have moved forward with conservatorship, 13 of which have been successfully remained in the community. many of those cases are individuals where they were at risk of being evicted or were in the eviction process, and through the work with a.o.t. and collaboration with the conservator's office, we were able to save their housing, and they were able to remain in the community. on average, we work with individuals for 138 days. as i previously stated, given the needs of this population on the risk factors, it takes a significant amount of time to stabilize individuals in the community, to connect them to services, and also to help bridge them and make sure that that connection is well-placed

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before we move forward with closing the case. we want to make sure we are confident that they are receiving the clinically appropriate services and they will continue to remain engaged in the services. another important part of our evaluation is to obtain feedback from participants, family members, and stakeholders, from participants, we have 80 6% of individuals reporting they're hopeful about their future, 80 2% reported feeling they were treated with respect, and one individual reported that a.o.t. made them feel safe. and regard to feedback from family members, family members have reported increased awareness of behavioural health services and behavioural health symptoms, and one family member recorded that a.o.t. was lifesaving further left one. in terms of feedback from stakeholders, generally stakeholders have reported an increased collaboration and coordination of care, and i think this is a really important part of our work, again, helping

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to bridge those gaps, but making sure the right people are talking to one another to support the individual. finally, i want to talk about the financial implications of this. so what we did here, as we looked at the daily rate for psychiatric emergency services, hospitalization at general hospital, and also jail contact. this does not take into account any reimbursement that we had from medi-cal or other insurance , but we wanted to look at the overall impact of this through our system, not just for san francisco, but at the state level. and this first graph is for psychiatric emergency services, second just for psychiatric hospitalization, and third is for incarceration. as you can see, because of the significant reductions that we have, there are also significant savings associated with them. in toto, there is an 80 3% reduction in monthly costs,

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which accounts for $430,000 each month. which is a great outcome to have we are hopeful that as we continue to work with individuals and continue the program, we will see this long lasting effects. this is something that we will continue to look at while the state only requires that we submit a report to them on court ordered individuals, it is because we have been so successful in engaging individuals in voluntary services, that as a department, it is important to look for the outcomes for those individuals as well as the program as a whole. that concludes my presentation and i'm happy to answer any questions that you may have. >> thank you for your presentation. any questions? >> on the financial implications , that is the combined voluntary and court orders. >> that is correct. >> did you brake that down just

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so that you could see and the court could then see what the difference was? is it the same proportion? >> i appreciate that question. we did not break it down, but we certainly could do it and report back if that could be helpful. >> you might be interested and perhaps there is an interest, as a second question, in terms of the voluntary verses court mandated individuals, is there a difference -- difference in the success rate? i did not get to figure that out from all of your data, but is there, you know, more success for the voluntary, or less for the court, or vice versa? >> we have very similar levels of success. again, for both populations, the biggest impact is around incarceration.

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i would say for psychiatric hospitalization, there is less of an impact, where individuals are court ordered. some individuals who are court ordered don't end up engaging in voluntary services, but generally, it is consistent. >> that might be interesting in terms of your study, and that would also make some sense, voluntary would probably be more inclined to want to get better. i just think the breakout might be -- >> absolutely, happy to do that. >> i had a couple questions. thank you for your presentation, it is very interesting and hopeful. the first question is, this is preliminary data, so is there other types of data that you are working on that is not yet here in the presentation that might be informative that we could be anticipating? >> so regarding the statistics,

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there aren't other data points. we have a larger report that goes to the state, that we have included which has a lot more information in it, but regarding those negative outcomes, this is the data that we have. we only sate is preliminary because it is an ongoing process to gather this data, and we hope to see further impacts as the years go on. >> thank you. the second question is, given that this is three years worth of data, are there targets that you are setting for out years based on the success and experience on this program? >> in terms of the impact that we imagine we will see? >> it is sort of range of target so you might be putting in terms of the number of individuals that are impacted and the types of impact that you are expecting >> in terms of the number of people that are impacted, of course, one of the things that is important for us to do is to regularly do presentations for individuals who aren't qualified and requesting party is, so that we can ensure that we are reaching the population that

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a.o.t. is intended to. that is something we continue to do, and we have a goal of doing ten presentations a year, although we typically far exceed that. so that is regarding reaching the population. of course, we need those referrals to come into be able to work with them, which is why we focus on the presentations around that. in terms of what we'd it would anticipate in terms of outcomes, we haven't set any goals for that. i do appreciate that and i think it is something that we should look at because this is new data , and we haven't been at a point where we have set goals for ourselves yet. >> thank you. >> commissioner green? >> thank you, this is amazing work. i had two questions. one is, are there standard data that will be presented all these a.o.t. programs around the country that you are trying to get data and have standard things that you're looking at so

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you can share across areas and try to have something where you not only have your own data, but multiply it across systems? >> the treatment advocacy centre reports some of that, which they pull -- we all have to provide a report to the state each year. they pull that data from that. i will say, historically, the state hasn't fully defined what information they receive, and so sometimes it feels like it can be comparing apples and oranges. that is something that they are working to refine currently. as i noted, their primary focus is on individuals who have been court order to participate in treatment, which across counties is a much smaller population. i think it is where we will have the best data to look at across counties, but doesn't tell the full story of the work that is being done. san francisco started -- when we launched a.o.t. in 2015, we also started a quarterly conference

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call with other counties, and so we hosted that, and it is an opportunity for us to talk about different successes and challenges. i will say, in our experience, san francisco has really become at the forefront for consulting with other counties and implementing the program, so i am helpful -- hopeful that looking at the kind of data that we collect will help inform the state on what other counties do so we can better be able to answer that question. >> and the other question, do you think we are capturing all the people who could benefit from this program? in other words, they are various referrals. do you have data about that or do you feel that if you had the funding you could expand this to many more people because the impact is so clear, and i'm just wondering how you are thinking about that? >> it is always a complicated question. of course, we imagine that there are individuals who would qualify you don't get referred to as for a number of different reasons, which is why it is so important for us to do those presentations. generally i think our referrals,

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we have been really doing a good job of training referrals a building those relationships with the hospitals to make those referrals to us. but because of staff turnover, there are people who certainly can be missed. we are currently working on expanding our teams lately so we can do more of this presentations and outreach so that we can better capture individuals who would qualify, but it is hard to know exactly what that would be. >> thank you. >> one more question. i'm curious about the out-of-state referrals, and i'm assuming those are primarily voluntary, they're not court ordered. >> so that is the referral party who made the referral, so typically parents who are calling whose loved ones came to san francisco. i believe most of those cases, if not all of them accepted voluntary services ultimately. i can't think of any court cases

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where it was somebody who originally came from out of state. >> the other thing i'm curious about is a comparison of the number of referrals and san francisco county versus other counties, just given the type of population that we have, and where folks come from. it could be one of those data points that compare across, and maybe i don't know if it lends itself to some other outreach or targeting. >> i can say anecdotally, some other counties have more referrals that come into their program, but i think we are more refined in having -- we have done more trainings than most other counties have before implementation, so between march and november of 2015, we did a total of six trainings to individuals who are considered qualified requesting parties. the requirement is doing one training under the state law, and so it certainly is something that is important to us, and i do think it made a difference and that the referrals that we

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were getting were more appropriate for a.o.t., and so i think while we get, on total, less referrals, that we are more likely getting appropriate referrals and outreaching those individuals, and were successful and engaging those individuals. >> dr. chow? >> i just wanted to know that when this topic was taken up, it was extremely controversial, and i think it does -- the success that you have had, that this is another tool that is useful, and that all these individuals at this point have actually a benefit from it. of course, whether you will do any long-term studies will be another question, but i want to put it out there that while it was controversial in public, i think it has testified, not only because of finances, but because

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of the lives being helped here, that this is a useful tool. >> i appreciate that. >> your presentation has been very impressive data, which of course, brings up a lot of questions. the first is about contacted individuals. you mentioned their 295 referrals and it appears that roughly 40% of those have resulted in contacts, which is about four times more than what you had expected. could you give an example of referrals that does not result in contact, and also if you have ideas about why the number of contacts being made is higher than you anticipated. >> absolutely. to your first part of the question, i think that, you know , there are individuals who beget referrals for, "may not meet the criteria for us to outreach, for example, a family member may make a referral saying that they're not engaging in service since, but we are able to see that they are in

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fact working with a treatment provider, we speak to the provider and they are engaged in services. sometimes things like that will come up. there are also times when we may get an initial referral from the hospital, for example, but then the individual, while they are hospitalized, accepts voluntary services. we worked closely if someone ends up engaging in voluntary services so the provider knows that if they no longer engage in services that they should make referrals back to us. there are also -- this is less common, but there are times and we attempt to outreach an individual and we are not able to locate them, despite our best efforts, and we try to do that sometimes multiple times a week, different locations, different times, but can be unsuccessful. sometimes end up -- people and dipping out-of-state or out of county. those are reasons why we might not engage with an individual. and then i'm sorry, remind me of the second half of your question

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>> why you believe you have had four times more contact. >> right. i think part of it is that we have been really successful, and so i think we are getting more referrals related to that, and i think people being more knowledgeable about the program and understanding it, i think we also try very much to be flexible in cases that may need -- mead -- meet our criteria, but we may need more information to outreach the individual, and if they are amenable to engaging voluntary services, it helps to bring them into those services. >> and my second question was, i believe you mentioned when you take together the savings from the psychiatric hospital and incarceration, it works out to about $400,000 per month. how does that relate to the cost of administering this? >> in total, obviously it is a huge amount of savings that we would see per year.

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individuals that we work with would qualify for full-service partnerships are intensive case management. in terms of the cost of services , it is comparable to what we would see for other individuals who are working and receiving services through the system of care, but in terms of the reduction, there is still a huge cost reduction there, even with the additional services and support we are offering. >> thank you. >> of course,. >> any other questions, commissioner his? all right. thank you. >> thank you so much. >> there is a public comment request. welcome, dr. koufax. commissioners, your packets are out of order because at the very last minute, would change the order to make sure that we could -- i apologize that the next item will not be in order of your packet. the next item will be d.t.h. i.t. update. >> good afternoon, commissioners

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and the acting c.i.o. for d.b.h. -- i am the acting c.i.o. for dp h. >> today i will give you a 90 update forever quarter. it has been, since i talked to, i give you an update in march regarding an outage. i will go through the i.d. accomplishments and metrics, the strategic plan, and the project update followed by the organizational change management this month, i.t. will finish deploying, i'm sorry, let me start in the slide where i belong here. >> this month, we will finish deploying or making ready approximately 4,000 workstations

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as mentioned in my last update, primary care clinics were all upgraded to virtualized desktops , and on your slide, it says vdi, which is virtualized desktops, significantly reducing the time to launch. thank you. down at the bottom, that's okay. it is fine, thank you. the screen size for these clinics in other areas has been upgraded to 24 inches so it provides use of navigating. support training and approximate 10,000 providers and staff on epic, we have outfitted 26 training rooms with workstations to bring in the network. we continue to upgrade the

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i.d.f. clauses throughout d.p.h. these are clauses that connect the workstations and all peripherals in an area, in their hundreds of connections in each closet. it reduces any outage possibility for those workstations. i.t. continues to maintain a reliable network availability for 2019, the network for the first quarter has been up 99-point 9% of the time. we successfully installed and i.t. service management system in march. this was one of the e.a. chart reading tasks to enable i.t. to have a system to better manage ticketing for incidents, and finally, a system to enable i.t. to manage assets along with the knowledge database that will allow i.t. to provide faster and better response time to end users. this system is called service now and will also allow i.t. to produce benchmarking and compare ourselves to interstate standards. i.t. is using a system today that we have had around for 18 years. we're happy to have it replaced.

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i show you this and each quarter that i come in. right now i'm showing you in comparison to 2015, for the first quarter of 2019. we have averaged 1.33 incidents per month, and our incidents, we have one significant outage that i brought you in march where we cause an extended outage of critical systems. facilities and i.t. have corrected the alerting so next and out outage would not happen again. we continued to meet and we are still working on root cause analysis. we're looking just working with two things going on there. one is the chiller company and one is the system that does the control around when it would go to another chiller if the first chiller wear out. the service desk continues to have an excellent metric for resolution tickets and users finding the service desk helpful i will orient you to the layout of this. this is a plan that shows

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strategies on the left, and i will bring the strategies in. i will just bring them all in so they are here. on the left, and on the right-hand side, we are showing d.b.h. true north and the alignment of the strategies to true north. once the c.i.o. comes on board, which i believe we are having more interviews week, so i am anxious for that, we will be working with the promotion office to build out the plans for the critical strategies on the left-hand side. in 2014, the c.i.o. at that time presented a strategic plan to the health commission. the plan consisted of initiatives that would update infrastructure, modernize data centres and organize and train i.t. staff to support the new technologies and plainly to procure a new d.h.r. so five years later, most of those initiatives are on their way or near completion. last fall, leadership took a half-day retreat and we began to develop this five-year plan.

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from that effort, some essential i.d. strategies are identified and they were developed along with consideration for what technology changes were coming our way over the next five years for what we are anticipating. i met with each member of the d.p.h. executive staff, groups from informatics and other executives to get their input and their needs, requirements, identification of recurrent gaps wherewith i.t., and what they were thinking for technology strategy over the next five years. the plan you will see here is very high level. some of the categories will require developing plans over the next few months and sometimes years. this plan will provide the next c.i.o. i think it is a very running start on our organization and where we are and what needs to be done. i two of the things i want to highlight on here as i go through, probably most important to us right now are cyber security and resiliency and the unified communication collaboration and of course, epic being our number 1. it does remain our number 1 priority. wave one, which you are well

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familiar with at this point, we will go live on august 3rd. one goal is to meet them with stage seven within one year of the first wave. is a large organization of healthcare providers and has 72,000 members. it stands for the electronic medical record adoption model, and they actually measure how we are utilizing our e.i. chart and ability with its. for reference, a couple of years ago, you may have been three at this point, san francisco general went to him and they assessed us and said we were at stage six. they changed their data each year to how they will qualify so we would know longer qualify for stage six, but we were at that time. for ambulatory, we were at stage three. within the next three years, d.b.h. will complete deployment of epic as a further goal

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outside their. we want to roll it out beyond those institutions and to maternal child health and adolescent clinics jail health and behavioural health. meanwhile, we will continue once we are live with optimization and upgrades which will be part of the ongoing support for epic. d.p.h. will continue with infrastructure monitors a -- monitoring, your next strategy down, in cooperation with maker -- major facility upgrades and projects. will also develop a strategy by 2021. d.p.h. has digitalized over 800 servers by now, and we have the hardware on site, so as we evaluate the lifecycle of the hardware, will be looking to see if it is more efficient and economical to go to the cloud. cyber security is a very high priority along with resiliency, meaning business continuity. [please stand by]

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>> this will require retraining staff and it will increase with utilization of technology over the next five years. i'm combine kpi services and driven transformation are central in improving communications with i.t. and

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external to i.t. are a ness si. -- necessary. with the service management system we'll have a lot of benefits. a lot of which are metrics in being able to benchmark. for the last five years, i.t. internal communications and all hands meeting were minimal. over the last nine months webex meetings have been held and internal i.t. newsletter has been generate and for the first time i.t. communications have started with initial efforts to update and consolidate various internet sites to inform the user community of i.t. services, how to contact i.t. and what to expect from i.t. and technology. major incident management continues to evolve and improve and will stay a focus over the next several years. as the governance will be an an

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going setting for portfolio management as we post in the epic wave 1 live event. for the next tech lifestyle management with new supporting technology contracts had to be complete and systems installed prior to go live, i.t. has worked with contracts an legal to streamline the process. i.t. will use the process to model all other technology contract and implementation. a review board has been establish for standards and solutions. they will work with other teams to establish technology life cycle management and ensure collaboration and communication. unified communications and collaboration is something that when d.p.h. has traditionally

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focussed on infrastructure and service support are clinic in revenue system. what has not been supported is something leaders have found to be a large gap for daily operations. d.p.h. i.t. will develop a governance structure and provide support and training for common technologies we have not in the past such as video conferencing, electronic signature, software, document management, communication strategies such as team collaboration and internet site usage and share point usage. a new organizational structure will focus on closing the large lab. information governance. we brought it up as a readiness initiative with epic and it's governance overseeing data governance and analytics governance and data sharing, research, digital services and the master patient index. as part of the information

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governance a warehouse will be implemented for long-term data use. there's been a day in the system build so if you are looking at the system configuration in january the date test for training had been completed however, we have remaining what are called build buckets with epic so build bucket five and build bucket six and pre-live build bucket as well. we are extending that out. right now we're anticipating and it looked good. we had a report out today april 19th, build bucket will be done and we hoped to vit done april 14 and we're days out from the date but will be